88-537 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA C M� Telephone (209) 466-6781 PERMIT EXPIRES 1"YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District fon a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for welllpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address g^ Cityf.r¢ L�rPo-ot Size PM Owner's Name. Address Phone i Contractor pe ,i ZZ E� Address tLicense No: Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ E PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE F FOUNDATION AGRICULTURE WELL OTHER WELL L PITS/SUMPS INTENDED USE y TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial a ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ` t, 1'1 Public ❑ Others ❑yDelta Depth of Grout Seal "" ,Type of Grout I I Irrigation a --Approx. Depih I i Eastern Surface Seal Installed by - =Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction EDWell Diameter x Sealing Material atop-50't"__ Al " Depth 1 " Filler'Ma"terial IBelow 501 b 1 TYPE OF SEPTIC WORK: NEW INSTALLATION [.] REPAIR./ADDI'nON EJ DESTRUCTIO (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial 'Other tA` Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: 4� Water table depth SI PTIC TANK ❑ "Type/MfgCapacity f No. Compartments PKG. TREATMENT PLT. ❑ t Method of Disposal ,. Distance to nearest: Well Foundation Property Line a + LEACHING LINE ` ❑ No. & Length of lines k Total lengtVsize FILTER BED r i CJ Distance to nearest Well E Foundation I "Property Line SEEPAGE PITS 11 Depth ' Size I Number SUMPS i ❑ Distance to nearest: Well f - Foundation i Property Line "DISPOSAL PONDS ❑ ' �.Y 4 ` I hereby certify that I;have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations"of the San Joaquin Local Health District. I Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in,such manner as to become subject to workman's compensation laws of Caiiftirn ." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issuedll-employ persons subject to workman's compensa-tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side.- r Signed X TiNe: _�-----�� Date: 3�� 0. FOR DEPARTMENT USE ONLY w 3_1 `_ Area Application Accepted by �P�....r--� x w►AC—�d. Date !l Pit or Grout Inspection by Date .Final Inspection by { Additional Comments: 4( k ❑ Stk 466-6781 t ❑ Lodi 69-3621 ❑ Manteca 623-7104 ❑ Tracy 635-6365 I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.0. Box 2009, Stk., CA 95201 F � r FEE AMOUNT DUE AMOUNT REMITTED CAS CK RECEIVED BV PATE PERMET'NO. INFO / ' g -s P ' + EH 124 fREV.ti115) C"r�� . . ` �- EH 14-4-2fl J